Recent advances in treatment of acute mania

Standard and more recent advances in treatment of acute mania are reviewed with special emphasis on controlled studies. Lithium is still the drug of choice and the most common treatment for mania, but some of its limitations have become more apparent, and specific indications for its use are defined. Alternatives to lithium are recommended for psychotic, rapid cycling, severely manic, and lithium-refractory patients. Neuroleptics are effective and used commonly but carry risks of long term side effects. Substantial reduction in neuroleptic dose and duration of exposure is probably feasible in many patients. Neuroleptic-lithium combinations are popular but do not have clear advantages over treatment with a single drug in the initial treatment of acute mania. These combinations have also been associated with increased neurotoxicity. Carbamazepine, both alone and in combination with lithium, has been used increasingly over recent years. Its efficacy is comparable to lithium, but clinical features predicting responsiveness may be different for these two drugs. Carbamazepine-neuroleptic combinations offer little advantage over neuroleptics alone. Valproic acid, verapamil, clonazepam, lorazepam, benzodiazepine-neuroleptic combinations, clonidine, tryptophan, propranolol, and electroconvulsive therapy are also popular, but their effectiveness has not yet been adequately confirmed by controlled studies.